Approval Request - Tranpsport of Donated Fodder - Amazon S3



|[pic] |APPROVAL REQUEST |

| | |

| |TRANSPORT OF |

| |DONATED FODDER |

|Has the Community Organisation applied previously for assistance from the NSW Rural Assistance Authority? |Yes |No |

|NOTE: If you select ‘Yes’ please provide your 6 digit BP number, if available. |BP: 5      |

1. DETAILS

|Name of Organising Committee/Group: | |

|      |

|      |

|Postal Address: |

|      |

|      |Postcode      |

|ABN (if applicable):       | |

|Phone:       |

|E-mail:       |

|Name of Carrier: |

|      |

|      |

2. Please provide a detailed statement of proposed fodder donations

Please note, details of donation will be provided to the Rural Financial Counselling Service in the benefiting area to promote coordination of effort

|Including nature of emergency eg drought/flood and approximate number of farmers will benefit from donation. |

|      |

3. PROPOSED MOVEMENT DETAILS

|Movt No |Date of Movement |Type of Fodder |Net Weight (Tonnes) |Loaded Distance (km) |Cost per km |

|1 |  /  /     |      |      |      |      |

|2 |  /  /     |      |      |      |      |

|3 |  /  /     |      |      |      |      |

|4 |  /  /     |      |      |      |      |

|5 |  /  /     |      |      |      |      |

| |TOTAL |      |

|Movt No |Movement from |Movement to |

|1 |      |      |

|2 |      |      |

|3 |      |      |

|4 |      |      |

|5 |      |      |

4. STATEMENTS

General Statement

Any person who knowingly and with intent to defraud the NSW Rural Assistance Authority or another person, files a claim for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties.

Privacy Statement

The information in this claim form is provided voluntarily and is being collected by the NSW Rural Assistance Authority for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this claim to contractors engaged by the Authority or to either State or Commonwealth government agencies. We will supply you with details of those that we have disclosed information to, if you apply to us in writing.

Not providing the information requested in this claim form or providing false or misleading or incomplete information may impact on the ability of the Authority to accurately assess the claim.

The NSW Rural Assistance Authority agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely.

You may access or correct your personal information by contacting the Authority by telephone on 1800 678 593 (toll free) or by writing to: Manager Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, 2800. Calls to “1800” numbers from your home phone are free. Calls from public phones and mobiles may be timed and attract charges.

5. ORGANISING COMMITTEE / GROUP DECLARATION

I, (full name) __________________________________________

of __________________________________________

in the State of New South Wales, being an official of an Approved Community Organisation/Group, do hereby solemnly and sincerely declare and affirm that:

1. the approval sought in this form relates to the movement of donated fodder to feed stock on drought/disaster (please delete whichever is not applicable) affected properties as detailed; and

2. I have read the latest Scheme Information and Guidelines in relation to the assistance applied and understand the conditions and requirements therein;

I understand that:

3. deliberately giving false or misleading information is a serious offence;

4. the NSW Rural Assistance Authority can make relevant enquiries to ensure the correct entitlement is received;

5. personal information is protected and can be given to someone else where state/territory or Commonwealth legislation requires or where I give permission;

6. statistics may be collected and analysed in such a way as to protect my anonymity.

I do solemnly and sincerely declare that the particulars on this form and associated with this application are true and correct.

I agree to relevant details of this application being provided to the Rural Financial Counselling Service in the benefiting area to promote coordination of effort, and to provide feedback in relation to this Scheme.

Signed ________________________________________ (Official of Community Organisation)

Declared at ____________________ on ____ / _____ / _______

6. TRANSPORT OPERATOR (CLAIMANT’S) DECLARATION

I, (full name) __________________________________________

of __________________________________________

in the State of New South Wales, being a transport operator contracted by __________________________________________. to transport donated fodder to __________________________________________, do hereby solemnly and sincerely declare and affirm that:

1. the approval sought in this form relates to the movement of donated fodder to feed stock on drought/disaster (please delete whichever is not applicable) affected properties as detailed; and

2. I have read the latest Scheme Information and Guidelines in relation to the assistance applied and understand the conditions and requirements therein;

I understand that:

3. funds for the scheme are limited and that claims for transport of donated fodder in excess of the approved amount/s will not be paid;

4. deliberately giving false or misleading information is a serious offence;

5. the NSW Rural Assistance Authority can make relevant enquiries to ensure the correct entitlement is received;

6. personal information is protected and can be given to someone else where state/territory or Commonwealth legislation requires or where I give permission;

7. statistics may be collected and analysed in such a way as to protect my anonymity.

I do solemnly and sincerely declare that the particulars on this form and associated with this application are true and correct.

I agree to provide feedback in relation to this Scheme.

Signed __________________________________________ (Transport Operator)

Declared at ____________________ on ____ / _____ / _______

7. LODGEMENT OF APPLICATIONS

Applicants can lodge completed application forms including required documentation with the NSW Rural Assistance Authority by post, email, facsimile or personal delivery at:

Post: Locked Bag 23

Orange NSW 2800

Email: rural.assist@raa..au

Fax: (02) 6391 3098

In person: 161 Kite Street

Orange NSW 2800

Telephone: 1800 678 593 (Toll Free)

Website: raa..au

Applications must be received by the NSW Rural Assistance Authority no later than the closing date. Applications received after the advertised application period closing date,

in any other circumstances will not be accepted.

If you have difficulty understanding or completing this form you should seek the assistance of your rural/financial counsellor, business advisor, accountant or a trusted family member/friend.

Language Services (Interpreting and Translating) are available by contacting Multicultural NSW

on 1300 651 500 or by visiting languageservices@multicultural..au.

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